Reasons for Rejection of Medical Claims and How to Avoid It
1. Incorrect patient’s info about insurance ID or date of birth. If you’re submitting electronic claims, you should AVOID use of entering characters like a dash and an asterisk in between the insurance number because they may be termed as unrecognizable by digital devices. Simply check on this issue together with your service provider. Always make a copy of your individual’s main & secondary insurance card on record of the front and rear side. Ensure that you acquire a copy of the brand new card incase of any change.
2. Patient lack of coverage or terminated coverage during the service period may also be a good reason for denial of a claim. That is why, it’s quite crucial that you check on the patient’s benefits and eligibility before you see the individual. Unfortunately, some practices go ahead with service provision without checking those details and wind up not paid for the services provided to the patient.
3. CPT/ICD9 Coding Issues (demands 5th digit, obsolete codes). Be careful with your secondary code. Claims could be rejected simply due to the secondary CPT/ICD9 code! Again talk about finding a solution the coding mistake rather than how much you need to get reimbursed. Most of the insurance business help you with codes, and they also advise you on outdated codes or codes that require a 5th digit. Be polite to the claims department.
4. Incorrect use of modifiers. Be cautious with bilateral procedures, modifiers for multiple procedures, etc.
5. No precertification or preauthorization obtained if needed. It is hard to file an appeal once the claim or service was non-precertified. Prevent it from occurring.
6. No referral on a document if needed. Note that HMOs always need a referral.
7. The individual has other primary insurance, or the claim is to get workman’s comp or automobile accident claim! It is the duty of your front desk personnel to receive all the necessary information before the patient could be seen. Keep in mind that if this is a workman’s comp or an auto incident claim, you need the number of the claim and the adjustor’s name.
8. The claim requires documentation & notes to support clinical necessity. A well documented medical records is a great practice.
9. Claim requires referring Physician’s info (together with UPIN of course!).
10. Late filing. Unfortunately, most of them don’t accept your charging documents on your computer that shows date you charged the insurance. They need a receipt from your electronic reception or to for postal mail, of course, they need a receipt also. If you are submitting claims by electronic means, be sure to generate transmission reports/receipts. Your reports have to read “approved” rather than “refused”. If you are Sending claims by postal or paper mail, it’s a good idea to send your certified claims complete with tracking number, and keep those receipts.